Slides for Novartis meeting - NZWCS · 2019-11-22 · First presentation - 2004 • Referral from...
Transcript of Slides for Novartis meeting - NZWCS · 2019-11-22 · First presentation - 2004 • Referral from...
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“Health & Wealth For Wales”
Atypical Wounds
Keith Harding CBE,FRCGP, FRCP, FRCS, FLSW
Professor of Wound Healing Research, School of Medicine Cardiff UniversityClinical Director Wound Healing Cardiff & Vale UHB
Medical Director Welsh Wound Innovation Centre
Ynysmaerdy, Pontyclun, Rhondda Cynon Taf
Senior Clinical Research Director A Star Institute Singapore
Visiting Professor LKC Medical School
Hon. Consultant National Skin Centre Singapore
Trudie Young RMN, RN, Dip.N, MSc, PGCE
Education and Training Director Welsh Wound Innovation Centre
Ynysmaerdy, Pontyclun, Rhondda Cynon Taf
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What are the causes of these wounds?
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Just when you thought it couldn’t get any worse?
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“Health & Wealth For Wales”
Reasons for concern in these patients ?
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Nick• 40 year old with spastic diplegia secondary to
Cerebral Palsy
• Immensely independent shoe shop owner from Hereford
• Recurrent foot ulcers necessitating amputation of toes
• Pain “makes me want to cry every morning”
Photographs used with patients permission
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First presentation - 2004
• Referral from orthopaedic surgeon
• 1 year history of a painful and tender non-healing wound on the dorsum of the right foot
• No Diabetes
• No venous or arterial disease (duplex normal)
• No evidence of osteomyelitis (bloods & x-ray)
• No evidence of malignancy (biopsy)
• Treated for recurrent infections: antibiotics, local antimicrobials and then debrided under EMLA
• Healed after 7 months
• Prevention: dependent oedema control & foot care
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Re-presented in 2008
Persistent ulceration
Extreme pain
Normal blood glucose
Treated with potassium permanganate and oral antibiotics.
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Toes fusedPainful
Month 0 Month 4
Recurrent InfectionWound enlarging
Pain
Month 15
Recurrent infectionPersistent wound
Pain
2008 - 2009
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Investigations (2008-9)
• FBC• Urea and electrolytes• Liver function tests • Glucose• Thyroid function• Bone profile • Serum globulins • Electrophoresis• Autoantibody screen• X-ray foot• ABPI • Arterial & Venous duplex scan
• Inflammatory markersCRP: 45mg/LESR: 60mm/hr
• Biopsy tissue microbial cultures: – Pseudomonas aeruginosa– Stenotrophonas maltiphilia
Normal:
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April 2009 - because of persistent pain and recurrent infection he was seen by a
vascular surgeon for a forefoot amputation
Right foot
Persistent Pain despite:Buprenorphine patchesTramadolParacetamol
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He then developed ulceration of the other foot
April 2009
Left foot Right foot
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4x
Ulcer edge
Right foot
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Perl Stain – Iron
Positive controlPatient
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ImmunohistochemistryCD34 – blood vessels
Kaposi’s sarcoma Patient
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Diagnosis?
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Acroangiodermatitisof Mali
• Syn. Pseudo Kaposi’s sarcoma
• original paper 18 cases associated with chronic venous leg ulcers
• Violaceous papules and plaques that coalesce and ulcerate
• Pathology: lobular capillary proliferation and spongiosis
• Ages 30-40 years
• Mostly males Mali JW et al. Arch Dermatol;1965;92:515-518
Chronic Venous Insufficiency
Acroangiodermatitis
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Left foot Right footCompression
August 2009Out-patient compression
therapy
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Nick and his business
happily re-united
Photographs used with patients permission
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The take home message…
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My Girlfriend...... HEIDI
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Ulcers: Differential Diagnosis
Patel GK, Grey JE, Harding KG. BMJ 2006; 332: 594-6.
Haematological
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Overall Management
Targeting the patient - setting targets
Symptoms
Healing
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Minimise Appearance
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What is most important problem ?
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Measures of Success?
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Systemic factors
Regional factors
Local factors
Targeting the wound
Wound
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Systemic Factors
Vasculitis
• Factitious Wound
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Regional Factors
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Easy to Heal ?
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Not so Easy now!!
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Local Factors
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Wound Factors
WHRU
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“Health & Wealth For Wales”
Common causesArterial Ulcer
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“Health & Wealth For Wales”
Venous Disease
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“Health & Wealth For Wales”
Diagnosis ?
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“Health & Wealth For Wales”
Venous Disease/Lymphoedema/Obesity/Immobility/Infection/ Pain / Renal Failure/ Cardiac Failure/ Malnutrition/ Depression/
etc !!!!
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“Health & Wealth For Wales”
Rheumatoid ArthritisDisease/consequences/drugs
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Diagnosis ?
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Progress over Time
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“Health & Wealth For Wales”
Leucocytoclastic Vasculitis
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“Health & Wealth For Wales”
Inflammatory causes of wounds
Vasculitis
Pyoderma gangrenosum
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Venous ulcer or PG?How do you know?
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“Health & Wealth for Wales”“Health & Wealth For Wales”
It can be treated-Dressings/devices/drugs/biological
agents
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Diagnosis ?
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Necrobiosis LipoidicaDiabeticorum
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NecrobiosisLipoidica Diabeticorum (NLD)
• NLD is an uncommon inflammatory skin condition
• NLD usually affects people with Diabetes Mellitus – 0.3% type 1 and type 2
• One third of individuals will have some form of dermatological condition
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD
• More common in female population
• Average age of onset 30 yrs old
• Can be present in non DM, precursor to the disease – monitoring
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD clinical presentation
• Red papules that slowly enlarge into erythematous non-scaling plaques with waxy indurated yellow-brownish telangiectatic centres and raised edges
• Plaques can precede ulceration by months/years
• Prevalent on the lower limbs also found on fingers, dorsum of hands, face, scalp, abdomen, interscapular region and penis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD clinical presentation
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD clinical presentation
• Self-limiting
• Can resolve spontaneously
• Recurrence and flare ups are frequent
• Reports of it occurring after tattoo and tattoo removal
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD complications
• Malignancy
• Secondary infection
• Unsightly scarring
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD differential diagnosis
• Granuloma annulare is a chronic asymptomatic dermatosis found on dorsum of the hands, feet and elbow and it can be difficult to distinguish from NLD
• Patients with sarcoidosis have similar presenting lesions
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD treatment
• Early treatment – low fat diet (unsuccessful)
• There are no recognized standard treatment, evidence currently available is insufficient to give definitive recommendations as regards the systemic treatment
• Systemic, intra lesional and topical application of corticosteroids
• NSAID
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“Health & Wealth for Wales”“Health & Wealth For Wales”
NLD treatment
• Immune suppressant therapy – Infliximab, tacrolimus, cyclosporin
• Asprin and pentoxifylline to modify blood flow
• Avoid trauma
• Glycaemic control
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Bedtime reading
• Back to basics; Undertanding NLD
• Wounds UK, volume 15, number 1, pages 40-46
• http://www.wwic.wales/publications-and-posters/published-articles
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Diagnosis ?
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Martorell’s UlcerWhat else could it be?
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Diagnosis ?
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Ehlers Danlos Type 4
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Hydroxyurea ulcer
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Nicorandil Ulcer
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Nicorandil as a Cause for Non Healing Wounds
June 2007 Sept 2007
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Angiosarcoma
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Marjolin’s Ulcer
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Squamous Cell Carcinoma
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Malignant Melanoma
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Diagnosis ?
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“Health & Wealth For Wales”
Factitious Ulcer
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Cutaneous Calcification
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Diagnosis ?
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Diagnosis ?
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Systemic Sclerosis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calcium• Skeletal muscle and myocardial contraction
• Neurotransmission
• Blood coagulation pathway
• Cell-to-cell communication
• Keratinocyte proliferation, differentiation and adhesion
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calcium regulation & deposition
• Serum calcium is strictly controlled by the parathyroid hormone
• Insoluble calcium can be deposited in the skin and subcutaneous tissues
• Mural calcification – calcium in the walls of the arteries
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calcinosis cutis
Calcinosis Cutis
Dystrophic calcinosis
Metastatic calcinosis
Iatrogenic calcinosis
Idiopathic calcinosis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Dystrophic calcification
• Most common type of calcinosis cutis
• Multiple and local deposition of calcium
• Not found in internal organs
• Can be found in tendons and muscles
• Serum calcium and phosphate levels are normal
• Occurs in local tissue trauma – leg ulceration
• Dead tissue within the wound bed
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Dystrophic calcification
• Can remain unidentified until X-ray is performed
• Associated with connective tissue disorders –systemic sclerosis
• Wound bed contains grains of calcium
• Hard and firmly adhered to the wound bed
• Calcinosis universalis – rare, bands of calcium along the fascial planes, poor prognosis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Dystrophic calcification
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calcium deposits removed from a wound
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Metastatic calcification
• Abnormal calcium and phosphate metabolism
• Hypercalcaemia and hyperphosphatemia
• Secondary to Increased secretion of parathyroid hormone due to hyperparathyroidism (begin/malignant tumours)
• Tumours of the bone or bone marrow
• Paget’s disease
• Renal failure
• Vitamin D-related disorders
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Idiopathic calcification
• Normal calcium and phosphate levels
• Subcutaenous tissue – scrotum
• Paediatrics
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Idiopathic calcification
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Iatrogenic calcification
• Complication of extravasation of intravenous calcium chloride and calcium gluconate
• Localised elevated level of concentration of calcium in the tissue
• Painful calcified nodules
• Resolve in time following discontinuation of the therapy at the damaged area
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Warfarin-induced skin necrosis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Warfarin-induced skin necrosis
• Acute onset within 24 hours of taking warfarin
• Parathesia, odema, mild rash
• Develops and resembles clinical presentation of calciphylaxsis
• Full-thickness skin necrosis with deep subcutaneous ulceration
• Areas with increased subcutaneous fat –abdomen, buttocks, thighs, breasts
• Biopsy to distinguish from Calciphylaxis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calciphylaxis
• Now 5th Variant of Calcinosis Cutis
• Can have normal parathyroid and renal function
• Complication of renal transplantation and end-stage renal disease
• Dialysis patients
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calciphylaxis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calciphylaxis
• Common on lower limbs
• Purple-coloured mottling of the skin with blood-filled blisters
• Necrotic violaceous plaques
• Nodules
• Multiple painful non-healing ulcers
• Poor prognosis – inability to reverse the vascular disease, sepsis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calciphylaxsis
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“Health & Wealth for Wales”“Health & Wealth For Wales”
http://www.wwic.wales/publications-and-
posters/published-articles
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Calcinosis cutis treatments
• Lack of randomised controlled trials
• Metatstatic calcification – control of calcium and phosphate metabolism
• Parathyroidectomy
• Alteration in type of dialysis
• Alternative anticoagulant therapy
• Removal of the calcium deposits – local anaesthetic, surgical debridement
• Recurrence
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Diagnosis ?
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Hidradenitis Suppurativa (HS)
• Acneform disorder with follicular occlusion
Chronic inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions.
Zouboulis et al 2015
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS
• 1% prevalence in Europe
• Rare in children and associated with hormonal disorders
• Predominance in the female population (hormonal)
• Incidence is higher in African and Afro-Caribbean population
• Starts around puberty
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS course of the disease
• Most individuals only suffer from mild form of HS
• Eventually disease burns itself out
• Scarred and fibrotic skin
• Recurrence is common
• Average duration of the disease 19 years
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS pathophysiology
• Uncertain aetiology
• Acute or chronic disease
• Skin disease of the hair follicles especially the follicular pilosebaceous unit
• Not a classical infectious disease, initial sterile process
• No unique bacterial agent
• Lack of lymph node involvement
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS diagnostic criteria
• Delay in diagnosis (8.5 years) – mistaken for a simple infected lesion
Have you had outbreaks of boils during the last six months with a minimum of two boils in one of the following five locations; axillae, groin, genitals, under the breasts, and other locations e.g. perianal region, neck and abdomen?
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS co-morbiditiesand risk factors
• Strongly associated with smoking and obesity
• Arthropathy
• Inflammatory bowel disease
• Metabolic syndrome
• Family history (genetic)
• Hormonal influence
• Not related to poor personal hygiene
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS differential diagnosis
• Localised Staphylococcal infection
• Cutaneous Crohn’s disease (associated with intestinal Crohn’s disease)
• Abscesses, pilonidal/dermoid cysts
• Sexually transmitted diseases
• Tuberculosis of the skin
• Primary or metastatic tumour
• Squamous cell carcinoma can co-exist with HS
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS treatment
• Pain relief – NSAID, opioids
• Topical clindamycin (antibiotic) – superficial and localised infection
• Systemic antibiotic therapy +/- clindamycin, rifampicin
• Immunosuppressant therapy – cyclosporin
• Corticosteroids – prednisolone
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS treatment
• Retinoids – Vitamin-A based medications, isotretinoin, more success in treating acne
• Anti-inflammatory – dapsone, cyclosporin
• Hormonal therapy - anti-androgens, females with peaks before menstrual cycle
• Biological therapy – adalimumab (Cochrane supported), infliximab, (inhibit pro-inflammatory cytokines), high cost, adverse effects, recurrence common on discontinuing treatment
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“Health & Wealth for Wales”“Health & Wealth For Wales”
HS treatment
• Surgical option if medical therapy is ineffective
• Localised excision and drainage (will not stop disease process)
• Wide surgical excision +/- negative pressure wound therapy
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“Health & Wealth For Wales”
![Page 106: Slides for Novartis meeting - NZWCS · 2019-11-22 · First presentation - 2004 • Referral from orthopaedic surgeon • 1 year history of a painful and tender non-healing wound](https://reader034.fdocuments.in/reader034/viewer/2022050422/5f91acf31b1f834aa843aad0/html5/thumbnails/106.jpg)
Bedtime reading!
Back to basics; understanding Hidradenitis Suppurativa
Wounds UK 2018, vol 14, no 1, pages 51 – 55http://www.wwic.wales//uploads/files/documents/Professionals/New%20Articles/hydradenitis%20suppurativa.pdf
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Diagnosis?
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“Health & Wealth for Wales”“Health & Wealth For Wales”
Venous Ulceration does damage to your tattoos!!!!
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Conclusions
• Many pathologies can cause chronic wounds
• Diagnosis is needed before Treatment
• Consider HEIDI• Treatment can consist of
DressingsDevicesDrugsSurgeryBiological agentsCombinations of above
• Wounds are diverse and challenging
• Need an MDT approach